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Patriot Travel

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Applicant Information

US CitizenUS Citizen

If you are a US Citizen, choose yes. All others choose no.

Applicant Date of Birth Date of Birth

Applicant Date of Birth Date of Birth

Coverage Dates

Coverage Start Date Start Date

Coverage Start Date Start DateCoverage Start Date Start Date

Date that coverage should begin. This date cannot be more than 6 months from today.

Coverage End Date End Date

Coverage End Date End DateCoverage End Date End Date

This date cannot be more than 12 months from the date coverage begins.

Yes, I need dependent coverage.

Dependent Coverage - Dates of Birth

SpouseSpouse

Only specify the spouse date of birth if this person is to be covered.

SpouseSpouse

Only specify the spouse date of birth if this person is to be covered.

Child 1Child 1

Only specify the date of birth if this person is to be covered.

Child 1Child 1

Only specify the date of birth if this person is to be covered.

Child 2Child 2

Only specify the date of birth if this person is to be covered.

Child 2Child 2

Only specify the date of birth if this person is to be covered.

Child 3Child 3

Only specify the date of birth if this person is to be covered.

Child 3Child 3

Only specify the date of birth if this person is to be covered.

Child 4Child 4

Only specify the date of birth if this person is to be covered.

Child 4Child 4

Only specify the date of birth if this person is to be covered.

Child 5Child 5

Only specify the date of birth if this person is to be covered.

Child 5Child 5

Only specify the date of birth if this person is to be covered.

Child 6Child 6

Only specify the date of birth if this person is to be covered.

Child 6Child 6

Only specify the date of birth if this person is to be covered.

Child 7Child 7

Only specify the date of birth if this person is to be covered.

Child 7Child 7

Only specify the date of birth if this person is to be covered.

Child 8Child 8

Only specify the date of birth if this person is to be covered.

Child 8Child 8

Only specify the date of birth if this person is to be covered.

Add more dependents

Coverage Options

Adventure SportsAdventure Sports

The Adventure Sports Rider is available on both Patriot plans for those up to the age of 65. Certain adventure sports are covered (to the maximum amounts listed on the Benefits page) as long as they are engaged solely for leisure, recreation, or entertainment purposes. This is only a summary of Adventure Sports coverage and exclusions, please see Exclusion 8 for the full list of covered activities, exclusions and more information

Personal LiabilityPersonal Liability

Provides limited protection where Insured is responsible for Injury or personal property damage to a Third Party during coverage period. For injury to a third party, there is a $2,000 limit after a $100 deductible. For damage to third person property, there is a $500 limit after $100 deductible.

End of Trip Home Country CoverageEnd of Trip Home Country Coverage

For every five months of continuous coverage you purchase, you can purchase one month of home country coverage as an accommodation and supplemental travel benefit, up to a maximum of two months. The total period of coverage may not exceed 12 months.

Evacuation PlusEvacuation Plus

This optional rider is available to insureds up to age 65. It provides coverage for medical evacuations for sudden and unexpected medical conditions that are non life-threatening, and where hospitalization is medically necessary. This coverage is in addition to the Evacuation coverage already included in the plan. It also offers coverage for evacuations as a result of a natural disaster. This rider must be purchased for a minimum purchase of 3 months regardless of the minimum number of days being traveled.

Enhanced AD&DEnhanced AD&D

This optional coverage is available for the primary insured person only. This coverage is in addition to the Accidental Death and Dismemberment already included in the plans. Coverage must be purchased for a minimum of three months.

Need Assistance?

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Direct:

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